Appendices

Appendix A - 1117B.5.11 Cleaner air symbol of the California Code of Regulations

1117B.5.11 Cleaner air symbol. "STRICTLY FOR PUBLICLY FUNDED FACILITIES OR ANY FACILITIES LEASED OR RENTED BY STATE OF CALIFORNIA. NOT CONCESSIONAIRES". This symbol shall be the standard used to identify a room, facility and paths of travel that are accessible to and usable by people who are adversely impacted by airborne chemicals or particulate(s) and/or the use of electrical fixtures and/or devices. When used, the symbol shall comply with Figure 11B-40.

1117B.5.11.1 Color and size of symbol. The symbol shall be used when the following minimum conditions are met. The symbol, which shall include the text "Cleaner Air" as shown, shall be displayed either as a negative or positive image within a square that is a minimum of 6 inches on each side. The symbol may be shown in black and white or in color. When color is used, it shall be Federal Blue (Color No. 15090 Federal Standard 595B) on white, or white on Federal Blue. There shall be at least a 70% color contrast between the background of the sign from the surface that it is mounted on.

Strictly for publicly funded public facilities or any facilities leased or rented by State of California. Not concessionaires.

* In 1117B.5.8.1 (Symbols of Accessibility) the title of this section is incorrectly worded, which is causing misunderstanding regarding proper standard reference. Change title to read 'International Symbol of Accessibility.' This will be submitted for correction in Rulemaking. CALIFORNIA ACCESS COMPLIANCE REFERENCE MANUAL . DIVISION OF THE STATE ARCHITECT Chapter 11B Part 2 Title 24 California Code of Regulations 110 November 1, 2002

1117B.5.11.2 Conditions of use. Use of the cleaner air symbol is voluntary. The cleaner air symbol shall be permitted for use to identify a path of travel, and a room or a facility when the following is met.

  1. Floor or wall coverings, floor or wall covering adhesives, carpets, formaldehyde-emitting particleboard cabinetry, cupboards or doors have not been installed or replaced in the previous 12 months.
  2. Incandescent lighting provided in lieu of fluorescent or halogen lighting, and electrical systems and equipment shall be operable by or on behalf of the occupant or user of the room, facility or path of travel.
  3. Heating, ventilation, air conditioning and their controls shall be operable by or on behalf of the occupant or user.
  4. To maintain "cleaner-air" designation only nonirritating, nontoxic products will be used in cleaning, maintenance, disinfection, pest management or for any minimal touch-ups that are essential for occupancy of the area. Deodorizers or Fragrance Emission Devices and Systems (FEDS) shall not be used in the designated area. Pest control practices for cleaner-air areas shall include the use of bait stations using boric acid, sticky traps and silicon caulk for sealing cracks and crevices. Areas shall be routinely monitored for pest problems. Additional nontoxic treatment methods, such as temperature extremes for termites, may be employed in the event of more urgent problems. These pest control practices shall not be used 48 hours prior to placement of the sign, and the facility shall be ventilated with outside air for a minimum of 24 hours following use or application.
  5. Signage shall be posted requesting occupants or users not to smoke or wear perfumes, colognes or scented personal care products. Fragranced products shall not be used in the designated cleaner-air room, facility or path of travel.
  6. A log shall be maintained on site, accessible to the public either in person or by telephone, e-mail, fax or other accessible means as requested. One or more individuals shall be designated to maintain the log. The log shall record any product or practice used in the cleaner-air designated room, facility or path of travel, as well as scheduled activities, that may impact the Cleaner-Air designation. The log shall also include the product label as well as the *Material Safety Data Sheets (MSDS).

1117B.5.11.3 Removal of symbol. If the path of travel, room and/or facility identified by the cleaner air symbol should temporarily or permanently cease to meet the minimum conditions as set forth above, the cleaner air symbol shall be removed and shall not be replaced until the minimum conditions are again met.

Appendix B—Southwest Community Health System Policy Guideline

Southwest General Health Center (SWGHC)
Middleburg Heights, OH

POLICY 742
Effective Date: July, 2002

POLICY NAME: Multiple Chemical Sensitivity Syndrome (MCS)

Policy

Southwest General Health Center will provide guidelines to ensure optimal care of the patient experiencing Multiple Chemical Sensitivity (MCS) which is mutually established with the patient, family/significant other and health care team.

  1. INTERPRETATION
    Multiple Chemical Sensitivity (MCS), also referred to as environmental illness or chemical injury is a medical condition in which individuals develop symptoms from exposure to very low level of chemicals in the environment. The interdisciplinary team at SWGHC uses a collaborative process with the patient, physician, family/significant other and the health care associates to establish a safe environment, to promote healing and ensure comfort.
  2. OBJECTIVES
    An organizational approach to patient management with multiple chemical sensitivities includes:
    • Method to ensure patient is placed in a safe environment.
    • Method to facilitate identification of a MCS patient.
    • Method to verify competency of all associates providing direct and supportive care to the patient with MCS
    • Method to ensure patient's participation in developing their care plan.
    • Method to ensure patient/their families/significant others are educated about the need to communicate about any special care required.
  3. OVERSIGHT AND RESPONSIBILITY
    A coordinated organizational program to care for MCS patients will be developed by an interdisciplinary team. This committee will have the responsibility for assuring that all provisions of this policy are adhered to throughout the organization. The team will have representatives from:
    • Medical Staff
    • Nursing Services
    • Central Sterile Supply
    • Protection Services
    • Nutritional Services
    • Plant Operations
    • Environmental Services
    • SSA's
    • Pharmacy
    • Social Services
    • Administration
  4. SPECIFIC ROLES AND RESPONSIBILTIES OF INTERDISCIPLINARY TEAM
    • Medical Staff -Physician: Provides special instructions, treatments, diagnostic tests and medication orders. No treatments/medications should be administered to an MCS patient without prior approval of patient's private physician unless a life threatening emergency exists.
    • Nursing Services Role and responsibilities:
      • Identify the patient with MCS
      • Provide a safe patient care environment.
      • Develop an awareness, sensitivity and respect of patients' physical and emotional needs.
      • Develop a plan of care on daily basis with minimum of one staff member per each shift to attend medical needs of the patient.
      • Comply with the following when caring for the MCS patient:
        • be perfume and scent free (ie., no hair spray, no mousse gels, lotions, cigarette/smoking smells).
        • Do not use aerosol products (ie hair spray, deodorants). Non-scented, potassium salts, pump deodorant is acceptable. Baking soda (dry).
        • Do not wear new clothing which has not been laundered.
        • Do not wear clothing which has been freshly dry-cleaned.
        • Use only latex free gloves
        • Wash hands and apply gloves before entering the patient's room.
        • Be alert for any environmental triggers when following normal hospital procedures.
    • Central Sterile: Provides and ensures the unit with
      • Latex free products
      • Adequate supply of sterile linens
      • Adequate supply of other medical core items (ie. Sponges, dressings, securing devices).
      • Patient can provide their own linens if other methods are not satisfactory.
    • Protection Services: Provides assistance from the vehicle to hospital in a safe manner. (Turn vehicle engines off)
    • Nutritional Services: Recognizes different food sensitivities and follows certain guidelines to accommodate and meet individualized needs of the MCS patient.

      Special provisions may include but will not necessarily be limited to the following:

      • No processed foods of any kind including instant oatmeal, instant potatoes, and other prepackaged mixes, ie., gravies, sauces, and flavor packets as they may contain many additives.
      • Use no dyes, preservatives, sulfites, artificial flavoring or MSG.
      • Use no aerosol cooking sprays.
      • Use no artificial sweeteners.
      • Distilled water in glass containers to be provided by Nutrition Services, or patient may supply his/her own tolerated water for drinking.
      • Serve beverages which have not been processed with chemicals.
      • Nutrition Services will provide lactose free milk or a substitute such as soy or rice milk to those who require it.
      • Rigidly follow physician's orders regarding food restrictions.
      • Review food allergies within the food service to avoid allergic reactions.
      • Permit patient to supply his/her own tolerated food products. Nursing will provide a proper storage area for them.
      • Do not serve food or liquids in plastic or Styrofoam. Use only glass or ceramic dishes and cups which have been well rinsed to remove all traces of soap and chemical residues. Cellophane or plastic wrap packaging on room temperature food (i.e., crackers) is typically not a problem, however, caution must be used if toxic inks are used. Anything noticeably odorous can be a problem.
      • Remove treated i.d. menu paper from the tray and replace tray liners that may have become wet during transport.
    • Plant Operations: Plant Operations will not perform remodeling or painting within close proximity to MCS patient's room. These activities can be coordinated with the leadership of patient care area.
    • Environmental Services: will perform terminal cleaning.
      • Refer to Environmental Services Policy for MCS room cleaning.
      • Staff will check with the floor nurse before entering the patients room.
      • Environmental Services will coordinate with the patient's nurse for cleaning of the patient's room or performing any special cleaning tasks in the general area (ie., floor waxing or floor wax removal in the halls). Whenever there is a question of what may affect the health of an MCS patient, the floor nurse must be consulted.
      • Scented products, air fresheners, deodorizers or other additives should not be placed in any vacuum cleaner bag used anywhere in the health center. Use only unscented vacuum cleaner bags.
      • Do not use any other housekeeping products (garbage bags, paper towels, cleaning solutions) which contain fragrances or pesticides. These products should be stored in an area separate from disinfectants, soaps and other cleaning products. Do not store toilet paper, facial tissues or other patient items near fragranced or pesticide products.
    • SSA's: Will perform daily cleaning of the patient's room by using the following guidelines.
      • SSA's must wear clean gowns and caps when cleaning the room of MCS patient when patient is in the room.
      • Do not use any other housekeeping products (any plastic bags, paper towels, cleaning solutions which contain fragrances or pesticides). Do not use any air fresheners or deodorizers in patient's room.
      • Dust with a clean cotton cloth moistened with only water.
      • Use baking soda or Bon Ami cleanser for tubs, sinks and toilet.
      • Remove trash at least twice daily. Do not use plastic liners.
      • Do not leave patient trays in the room after meals.
    • Pharmacy
      Provides pharmaceutical care guidelines to patient, family and health care team members. The following guidelines are helpful in providing medications to patients with MCS:
      • Have patient bring medications to the hospital that he/she is currently using. If the physician desires the patient to continue using these medications, an order shall be written to state such.
      • Use glass bottles for IV solutions and any prescription medications that are to be administered intravenously.
      • Do not use any substitutions or generic drugs for medications ordered without patient or MD approval.
      • Be alert for standard ingredients MCS patients typically react to including but not limited to dyes, preservatives, artificial sweeteners and flavoring. Consider capsules instead of tablets.
      • Monitor medication by listing the patient's specific allergies on the patient's medication profiles.
    • Social Services
      Provides psychological support and interventions, assists patient and family with community resources and discharge planning.
    • Administration
      Provides support and assistance in developing a safe environment for MCS patient.
PROCEDURE:
  • Admitting will adhere to the following to assist all health care center personnel in caring for the patient:
    • Flag patient's chart clearly and boldly with MCS under the allergies.
    • Flag patient's chart to notify all other health center departments in advance of treating the patient so proper precautions can be made for necessary equipment and special supplies.
    • Indicate "MCS" on patient's allergy band.
  • Emergency Department:
    Will assist health care center personnel in diminishing any unnecessary discomfort and possible risks when MCS patient is brought into the Emergency Room. The following is initiated:
    • Immediately contact patient's physician for special instructions.
    • Immediately isolate patient from all other patients and visitors.
    • Place patient in an area which is not used to store any medical supplies or medications.
    • Keep a supply of sterile linens and gowns in the emergency room area.
    • Provide the least toxic pharmaceutical supplies and equipment.
    • Coordinate with all other health center departments to meet patients' needs.
    • Monitor the general environment the patient is placed in.
  • Patient's Room
    Staff will implement numerous measures to prevent unnecessary exposure.

    Prior to patient's occupancy:

    • Contact Environmental Services for terminal cleaning of the room.
    • Place new sharps container in the room
    • Contact CSS for sterile linen.

    During Patient's Occupancy:

    • Patient should be isolated from other patients and their visitors at all times to prevent reactions to products these people are wearing or using.
    • Place sign on patient's door stating: "Check at the nurses station before entering room".
    • Keep patient's door closed at all times and if necessary provide a clean cloth to seal bottom of door from hall odors.
    • Health care center personnel must wash their hands and apply hypo allergenic, non-latex gloves prior to entering the room of the MCS patient as these activities can trigger reactions in the patient.
    • No live plants or flowers permitted in the patient's room (mold and pesticides trigger MCS reactions).
    • No newspapers or treated paper permitted in patient's room. (3-part copy papers or chlorinated papers can be highly toxic and may affect breathing).
Approved
Trilok C. Sharma, M.D.
President, Medical Staff
Southwest General Health Center
L. Jon Schurmeier,
President
Southwest General Health Center
Appendix C—MULTIPLE CHEMICAL SENSITIVITY (MCS) PROTOCOL

Southwest General Health Center (SWGHC)
Middleburg Heights, OH

INITIATED DISCONTINUED  
Date Date SOUTHWEST GENERAL HEALTH CENTER
Time Time  
RN RN NURSING SERVICES

MULTIPLE CHEMICAL SENSITIVITY (MCS) PROTOCOL

PURPOSE: To outline the management and nursing responsibilities caring for a patient experiencing multiple chemical sensitivity (MCS).
LEVEL: Independent
SUPPORTIVE DATA: MCS is an acquired chronic disorder characterized by recurrent symptoms occurring in response to low levels of exposure to multiple unrelated chemicals. The symptoms generally occur in one of four categories: central nervous system, circulatory, respiratory and mucous irritation or metabolic that would include enzymes, blood, kidneys, GI tract, etc.. Patient with a history of maladaptive reactions to chemicals found in perfumes pesticides, detergents, household cleaners, etc. may have or develop multiple chemical sensitivities. Approximately 75% of those affected are women, possibly due to endocrine disruption. People in their 30s and 40s are most strongly affected as well as children and others who are more susceptible to the effects of pesticides and products containing toxic chemicals. The population most strongly identified with this condition include: industrial workers, teachers, nurses, sick building occupants and those living in chemically contaminated communities. Refer to Latex Sensitivity/Allergy Protocol and Hospital Policy #742 Multiple Chemical Sensitivity (MCS) Patient.
CONTENT: 1. Identify individuals at risk on admission in Emergency Room or Admitting.
Prior to Admission 2. Assign the patient to private room.
  3. Contact CSR for free tote (or nursing supervisor during night shift).
  4. Notify Environmental Services, Central Sterile, Pharmacy, Nutritional Services, and SSA of MCS patient admission.
Admission Assessment 5. Assess all patients on admission for allergies and maladaptive reactions.
  6. Place green allergy band on patient; mark Multiple Chemical Sensitivity (MCS).
  7. Place sign on patient's door stating: "Check at the nurses station before entering patient's room."
  8. Enter Multiple Chemical Sensitivity on all the orders sent in Cerner in Comments Box.
  9. Observe patient for following symptoms.
 
  • Fatigue
  • Memory loss
  • Depression
  • Nervousness
  • Lack of motivation
  • Visual problems
  • Hearing problems
  • Dizziness
  • Sleep disorders
  • Edema
  • Disorientation
  • Confusion
  • Irritability
  • Loss of logic sequencing ability
  • Loss of coordination
  • Hoarseness
  • SOB
  • Headache
  • Chest pain
  • Joint pain
  • Digestive difficulties
  • Sun or other rashes
  • Cold or heat sensitivity
  • Nausea
  • Tingling or numbness of extremities
  • Sinusitis
  • Pallor
  • Anemia
  • Salivation (usually from pesticides)
  10. Refer to Latex Sensitivity/Allergy Protocol
Patient Care 11. Report signs and symptoms exhibited by patient to physician.
  12. Obtain physician order for a special diet.
  13. Encourage patient to select their own menu.
  14. Allow patient to supply his/her own tolerated food products and dietary supplements.
  15. Retain patients dietary requirements in the patient's medical record for future reference.
  16. Encourage use of personal respirator and other protection methods while in Health Care Center.
Patient Safety 17. Reinforce all hospital employees and visitors to check with patient's nurse prior to entering patient's room.
  18. Maintain patient isolation from other patients and their visitors at all times.
  19. Transport patient with R-95 mask or personal respirator.
  20. Refrain staff caring for patient from wearing perfumes, scented lotions, hair spray, deodorants or other scented products.
  21. Educate hospital staff to wash their hands with unscented soap.
  22. -Apply- hypo-allergenic, non-latex gloves prior to entering the room.
  23. Instruct patient's family not to bring plants or flowers to the patient's room.
  24. Restrict newspaper in patient's room.
Patient Education 25. Discuss with patient/family Multiple Chemical Sensitivity if newly diagnosed patient.
  26. Reassure the patient with understanding of their chemically sensitive condition.
  27. Refer patient to Social Services to provide list of Community Services.
Documentation 28. Document Multiple Chemical Sensitivity in the patient's medical record, in the front of the chart, medication record and computer system.
  29. Record implementation/modification/discontinuation of protocols.
  30. Document vital signs and assessment findings on appropriate flow sheet.
  31. Document evaluative statement of the patient's response to interventions and lack of complications.
Emergency Interventions 32. If known, remove the offending object or person from patient's room.
  33. If necessary, remove patient from room to fresh air outside the building.
  34. Utilize charcoal and baking soda to absorb and remove odors from the room. Open windows if possible.
  35. Refer to patient's personal emergency protocol for reducing and diluting chemical reactions (water, food, baking soda, tri-salts, etc.)
  36. Communicate and cooperate with the patient whenever possible as the patient generally knows what will help.

REFERENCES

Multiple Chemical Sensitivity Syndrome, September 1, 2000, American Academy of Fa.
Mental Health Network, Editorial: April 2000.
SWGHC Pharmacy
Temple, Toni, Healthier Hospitals, 1996.

APPROVED

ICU QA 4/02; SC 05/02

REVIEWED/REVISED

New 09/01, 3/02

DISTRIBUTION

Generic